Risk managment
NITHYA M S
Sharjah
Summary
Dynamic Healthcare Quality and Patient Safety Leader with over 13 years of experience in enhancing hospital quality systems, ensuring accreditation readiness, and fostering a culture of patient safety across multi-specialty hospitals. Proven expertise in navigating NABH and JCI standards, with proficiency in AACI, Lean Six Sigma methodologies, and conducting thorough medical audits. Committed to driving continuous improvement initiatives that elevate clinical governance and optimize patient outcomes. Strategic thinker dedicated to implementing best practices that align with organizational goals and regulatory requirements.
Overview
16
16
years of professional experience
7
7
Certifications
3
3
Languages
Work History
Manager – Quality Excellence & Patient Safety
GKNM Integrated Medical Research & OP Centre
01.2021 - Current
- Designed and implemented a comprehensive Care Gap Observation System.
- Led patient experience improvement programs, enhancing outcome metrics.
- Strengthened accreditation readiness through internal audits and compliance.
- Executed Lean initiatives reducing operational delays.
- Improved patient satisfaction by 20%.
- Maximized performance by monitoring daily activities and mentoring team members.
- Cross-trained existing employees to maximize team agility and performance.
- Achieved departmental goals by developing and executing strategic plans and performance metrics.
- Improved safety procedures to create safe working conditions for staff.
Consultant – Quality & Patient Safety
Gandhi Medical Centre
01.2018 - 12.2020
- Managed full NABH consultancy for multi-hospital group.
- Implemented quarterly risk audits, RCA/CAPA frameworks.
- Designed COVID-19 safety risk-control measures.
- Trained 70+ staff on quality & safety standards.
Senior Quality Officer – Quality & Patient Safety
Ganga Medical Centre
05.2014 - 07.2016
- Reduced orthopedic ALOS by 18%.
- Conducted department audits with actionable insights.
- Presented dashboards at CAHO forums.
Senior Quality Officer – Quality & Patient Safety
K.G. Hospital
06.2009 - 10.2012
- Authored 250+ SOPs across hospital departments.
- Supported NABH accreditation readiness.
- Implemented KPI-based monitoring.
Education
MBA - Hospital & Health Systems Management
BITS Pilani
12-2025
Six Sigma Black Belt -
ISI
06-2010
B.E. - Electronics & Communication Engineering
Anna University
01.2009
Skills
- Proficient in NABH, JCI, and AACI accreditation processes
- Patient Safety & RCA/CAPA
- Clinical Governance & EPM
- Utilization Review & Audits
- Service Quality Improvement
- Lean Six Sigma
- Data Analytics & Dashboarding
- QMS Development & Gap Assessment
- Leadership & Change Management
- Team leadership
- Operations management
- Strategic planning
- Performance management
- Decision-making
- Project management
- Cross-functional teamwork
- Documentation and reporting
- Project planning
- Complex Problem-solving
- Key performance indicators
- Risk management
- Data analysis
- Trend analysis
- Problem-solving abilities
- MS office
- Multitasking
- Self motivation
- Computer skills
- Training and development
Websites
Certification
Internal Surveyor - AACI
Declaration
I hereby declare that the information provided is true and correct to the best of my knowledge.
Interests
Service Quality Improvement
Timeline
Internal Surveyor - AACI
09-2025
NABH 6th Edition Certification
01-2025
Certified Patient Safety Officer
08-2024
Advanced Stroke Centre Accreditation (2024)
03-2024
Lean Management in Healthcare Systems
01-2024
Quality Tools Master
06-2022
Manager – Quality Excellence & Patient Safety
GKNM Integrated Medical Research & OP Centre
01.2021 - Current
Certified Quality Implementer
09-2019
Consultant – Quality & Patient Safety
Gandhi Medical Centre
01.2018 - 12.2020
Senior Quality Officer – Quality & Patient Safety
Ganga Medical Centre
05.2014 - 07.2016
Senior Quality Officer – Quality & Patient Safety
K.G. Hospital
06.2009 - 10.2012
B.E. - Electronics & Communication Engineering
Anna University
MBA - Hospital & Health Systems Management
BITS Pilani
Six Sigma Black Belt -
ISI